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Peter Wetherall
Peter Wetherall
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Akathasia: The Worst Condition of All

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Nearly all published literature on neuroleptic drugs documents that akathasia is the most common type of extrapyramidal symptom resulting from the use of metoclopramide. What is akathasia? It is an inner sensation that prohibits you from being still. It is restlessness. It is feeling like something is constantly crawling under your skin. In some studies of neuroleptic drugs (the same class as metoclopramide) up to 40 percent of patients may experience akathisia. Jungmann and Schoffling (Lancet, 1982) administered 10 mg of metoclopramide, IV to subjects and found about 25% of these patients complained of akathisia. Subjects reported a strong desire to get up and walk around and flee from the test. The feelings were most often combined with the inability to think properly or read newspapers. In a more recent study, Schroeder et.al. (Anesth Analg, 1994) administered metoclopramide 10 mg, IV to 30 patients undergoing tubal occlusion. They found 20% of the patients developed akathisia and 43.3% seemed restless. The changes were associated with subjective sensations of jumpiness and discomfort.

Unlike other extrapyramidal symptoms, the occurrence of akathisia is not necessarily directly related to cumulativedose or duration of therapy

Check out Some of the studies specifically discussing the high incidence of akathisia is:

Albibi R, McCallum RW. Metoclopramide: pharmacology and clinical application. Ann Intern Med 1983Jan;98 (l) :86-95. “Metoclopramide antagonizes the effect of dopamine in the central nervous system…”. “Adverse effects, which may occur in up to 20% of patients, include drowsiness, lassitude, and akathisia….”

Alavi JB, Torri S, Glover D,Hurwitz D, Glick JH. High-dose oral metoclopramide. An effective antiemetic agent. Am J Clin Oncoll985Jun;8(3):260-5 reported that 51% of patients became restless, 9% haddystonic reactions. The restlessness was coded as akathisia.

Navari RN. Comparison of intermittent versus Continuous infusion metoclopramide in control of acutenausea induced by cisplatin chemotherapy. J Clin Oncol 1989Jul;7(7):913-.6.“Dystonic reactions, akatbisia, or diarrhea occurred in 20 of 58 patients” given intermittent metoclopramide “but in only eight of the 58 patients” given continuous infusions of metoclopramide.

Miller LG, Jankovic J. Neurologicapproach to drug-induced movement disorders: a Study of 125 patients. South MedJ l990 May; 83 (5) :525-32. “Of 125 patients with neuroleptic (dopamineblocking) drug-induced movement disorder, 63% had TD, 30% had parkinsonism, 34% had dystonia, 7% had akathisia and 2% had isolated tremor.”“Metoclopramide—induced movement disorders were found in 10 (8%).”

Schroeder JA, Wolfe WM, Thomas NH,Tsueda K, Heine MF, Loyd GE, Vogel RL, Hood GA. The effect of intravenousranitidine and metoclopramide on behavior, cognitive function, and affect. Anesth Analg 1994Feb;78(2) :359-64. Compared placebo 30, ranitidine 50 mg (32),met 10 mg (30), or both (31) . After refit 1 restless 5 drowsy. After met 20% akathisia, 43% restless, 27% drowsy. After both akathisia in 32%,restless 12%, drowsy 36%.

1995 Zaben AA, Al Herbish AS. Neurological side effects associated with unnecessary use of metoclopramide inchildren. Physician Alert 1995(Mar);15(2) report 24 children presenting withextrapyramidal syndromes after metoclopramide. They cite a publication by Hymnan: “Side effects occur in 20%-30% of patients treated with effectivedoses. Side effects include somnolence, restlessness, and insomnia, but themost troubling are dystonic arid extrapyramidal movements. Tremors, trismus,facial spasm, and oculogyric crises improve after withdrawal of the drug oradministration of intravenous diphenhydramine 1 mg/kg. Tardive dyskinesias maynot respond to drug withdrawal. Pediatric Gastrointestinal Motility Disorders25:379.”

Patterson D,Abell T, Rothstein R, Koch K, Barnett J. A double-blind multicenter comparison of domperidone and metoclopramide in the treatment of diabetic patients with symptoms of gastroparesis. Am J Gastroenterol 1999 May; 94(5):1230-4. Randomized IDDM to dornperidone 20 mg qid or metoclopramide 10 mg qid for 4 weeks. Met vsdom: somnolence 49% (severity 1.03) vs 29% (.49). Reduced mental acuity 33%(.62) vs 20% (.27). Akathisia, asthenia, anxiety, and depression more common and higher severity with met.

Anfinson TJ. Akathisia, panic, agoraphobia, and major depression following brief exposure tometoclopramide. Psychopharmacol Bull 2002 Winter;36(1) :82-93. Two days of metoclopramide led to akathisia, panic disorder, agoraphobia, and major depressive disorder leading to months of disability.